Prochlorperazine Combo Better Than Opioid Migraine Relief in ED

The opioid hydromorphone often is used as first-line treatment for migraine in the emergency department (ED). A new study calls that practice into question, however, suggesting that a better alternative exists.

The study published in the journal Neurology determined that the dopamine antagonist prochlorperazine — given in conjunction with diphenhydramine to prevent restlessness, a common side effect — is more effective than hydromorphone.

Prochlorperazine administered intravenously blocks the release of dopamine, helping to relieve the headaches.

"People go to U.S. emergency departments 1.2 million times a year with migraine, and the opioid drug hydromorphone is used in 25 percent of these visits, yet there have been no randomized, high-quality studies on its use for acute migraine," explained study author Benjamin W. Friedman, MD, MS, of Albert Einstein College of Medicine in the Bronx, N.Y.

The study also explored whether the use of an opioid drug could lead to addiction and return ED visits.

“While this study demonstrates the overwhelming superiority of prochlorperazine over hydromorphone for initial treatment of acute migraine, the results do not suggest that treatment with IV opioids leads to long-term addiction,” Friedman said. “In addition, the results should not be used to avoid the use of opioids for people who have not responded well to anti-dopaminergic drugs.”

For the study, researchers focused on 127 patients presenting to New York state EDs with migraine. To determine the rate of sustained headache relief after 48 hours, half of the participants were given hydromorphone, while the other half received prochlorperazine.

The study was ended with just 127 participants because 48-hour results showed that prochlorperazine was significantly superior to hydromorphone. The original endpoint was sustained headache relief after 48 hours, defined as having a mild headache or no headache two hours after receiving the drug and maintaining that level for 48 hours without requiring a rescue medication.

Results indicate that, by the 48-hour point, 60% of patients administered prochlorperazine had sustained headache relief, compared to 31% of those receiving hydromorphone. In fact, 31% of those given hydromorphone sought a second dose of the drug, compared to just 8% of those who received prochlorperazine. In addition, 36% of the hydromorphone group requested other pain-reliever drugs, compared to 6% of the prochlorperazine group.